Maternal Death Review in Eastern and Southern Africa
By
Dr Florence Oryem-Ebanyat
UNFPA Technical Advisor, RH/MH
Eastern and Southern Africa, Sub Regional Office
7 Naivasha Road,
P.O Box 2980
Sunninghill, 2157
Johannesburg, South Africa
Telephone: +27116035338
Fax: +27116035282
Email:
August 2010
Abstract
Objective: WHO, UNICEF and UNFPA with other development partners have been supporting African Ministries of Health to institutionalize maternal death review (MDR) since 2003. To evaluate the program, in 2010, I reviewed its current status, lessons learnt and challenges to success. Methods: A concept paper with objectives, the framework for maternal death review and the results of the 2007review was sent to 20 UNFPA Country Offices of Eastern and Southern Africa Sub- Region (ESA SRO) in March 2010. They were requested to collaborate with the Ministries of Health, UN partners and NGOs to update the information. Completed reports were returned by e-mail then processed and analyzed in MicroSoft Excel and included re-analysis of the report of 2007 for countries in ESA for comparison in 2010. Results: Seventeen countries completed the reports by 15th May 2010 although three countries provided inadequate information. The development of National policy and guidelines for MDR has improved from 35% in 2007 to 65% of countries; with maternal death being a notifiable condition in 50% of countries in 2007 and 65% in 2010 respectively. In 2007, only 4 countries (20%) reported that the government had allocated a budget for MDR; this has only improved to 30% in 2010. By 2007, in 15% of countries and 50% in 2010, national committees have been set up to plan, coordinate and implement MDR activities. In 2007, 70% of countries stated that facility-based MDR is the main method selected for conducting reviews of the causes of maternal death, while in 2010, 55% of countries use the FBMDR, while 20% use CEMD and a few use FBMDR in combination with CEMD, near miss and verbal autopsy. In 2007 45% of countries reported that national MDR guidelines had been developed and 77% had implemented the guidelines, while in 2010, 50% have developed guidelines and are all implementing them. While 55% of countries in 2007 reported that maternal deaths were reviewed and analyzed, by 2010, it was 65% of countries. Implementation of MDR should lead to local policy changes and improvement in quality of maternal health services in several countries. Among 11 countries (55%) reporting that analysis has been conducted in 2007, 8 (40%) reported that recommendations have been implemented at least at the health facility level. By 2010, 13 countries (65%) are conducting Maternal Death review but only six countries (30%) reported that the recommendations are being implemented. Conclusion: Although use of MDR is increasing in countries in East and Southern African, effective coverage is still low, in terms of establishment of fully functional committees at all levels and regular reporting and recording maternal death, review and analysis of data, and taking actions to avert deaths due to avoidable factors. The institutionalization of MDR requires political commitment, legal and administrative back up, financial support, capacity development, simplified reporting forms and procedures, coordinated support of development partners, involvement of professional bodies, and regular supportive follow up.
Appreciation.
I wish to extend my appreciation to all UNFPA COs who supplied the relevant information and made it possible to do the analysis and prepare the report.
Analysis of the MDR Reports in Eastern and Southern Africa Sub Region in 2010.
1.0 Introduction
Maternal Death Review (MDR) is a key element for improving the quality of maternal health care services by focusing on the preventable causes of deaths and what could have been done to avert the death. MDR does more than count maternal deaths; it looks beyond the numbers to study the causes and avoidable factors behind each death, leading to actions to improve quality of care and address factors that could have contributed to the death based on the findings. Universal reporting of maternal death is an important element of health management information systems as long as it leads to the allocation of resources to address the gaps.
2. METHODS
2.1 Introducing MDR in Africa
The process of introducing MDR systematically into all African countries started in 2003 when 3 UN agencies (WHO, UNFPA and UNICEF) collaborated with development partners and professional bodies to introduce MDR, aiming for institutionalization of MDR at the health system level. Four orientations for national MDR committees and program managers from 34 countries were held. All countries developed tentative national plans. During the orientations, 5 MDR methods were introduced: verbal autopsy, facility based MDR (FBMDR), near miss review, confidential enquiry of maternal death and criterion based clinical audit. “Beyond the Numbers” a WHO publication published in October 2004 was the main reference for orientations (1).
Table 1: The five methods of maternal death review:
Table 2; Orientation workshops and participating countries in ESA
Venue/ year / Participating countries1. / Malawi, 2003: / Ethiopia, Kenya, Malawi, Mozambique, Swaziland, Tanzania, Uganda, Zambia
2 / Zimbabwe, 2005: / Angola, Botswana,Lesotho, Namibia,Rwanda, Zimbabwe
3. / Benin, 2005: / None from ESA
4. / Gabon, 2007: / DRCongo, Burundi
5. / Mauritania, 2007: / Madagascar
2.1 The evaluation
In 2007, four years after the first orientations, WHO, UNFPA and UNICEF evaluated MDR progress in 43 countries in Sub Saharan Africa. The objectives of the review were: (1) To review progress made in MDR since 2003 and (2) To identify lessons learned and challenges encountered. A report of responses from 40 countries was made.
2.1.1 Process for MDR in ESA SRO:
This review in 2010 is a follow up, three years after the first review was done and covers the countries in Eastern and Southern Africa Sub- Region (ESA SR).
A concept note outlining the purpose of the review with the summary table of the findings of the MDR assessment conducted in 2007 was sent to all 20 UNFPA Country Offices of Eastern and Southern Africa in the last week of March, 2010. They were requested to coordinate with the MOH, UN partners and NGOs; and
1) Provide an update on the implementation/ institutionalization of the MDR based on the broad implementation framework for Africa to see the trends in institutionalization of MDR in ESA.
2) Share lessons learned; and
(3) To indicate the support required to institutionalize and scale up MDR in their countries and especially the 5 focus countries for Maternal Mortality reduction in ESA SRO in 2010 (Ethiopia, Malawi, Rwanda, Uganda and Zambia).
The broad implementation framework for institutionalization of MDR in Africa.
I. Creation of an active advocacy group at the national level.
II. Development of policy, guidelines and tools for conducting MDR.
III. Expansion of coverage from pilot to district and national scale.
IV. Enthusiastic government endorsement of MDR.
V. Collaboration and consultation with professional bodies, civil society, and donor agencies
VI. Legal reforms to support MDR (recognizing reproductive health rights, making maternal death a notifiable event)
VII. Incorporation of MDR into the formal governmental structure:
a. As part of the reproductive and maternal health programme of MOH and identifying a focal person,
b. assigning a budget line,
c. Involvement of other government ministries like the MO women affairs and Ministry of Justice.
VIII. Training (orientation/introduction, in-service and pre-service) at national, district and health facility levels
IX. Community involvement in developing program, creating awareness, and community participation in MDR Implementation.
2.1.2 The completed tables and details of the implementation were to be completed by end of April, 2010, but when information was not forthcoming Country Offices were reminded through emails and phone calls. All the qualitative and quantitative data were put into the Excel spread sheets for processing and analysis. The RH/ MH Adviser for ESA did the analysis and completed the report. An analysis of the findings of the first report in 2008 was made for countries in Eastern and Southern Africa in order to see the trends in the implementation of MDR in the sub region.
3. 0 RESULTS
3.1 Participating countries
Table 3.0 Countries participating in evaluation of MDR in ESACountries that responded
with adequate information / Countries that responded with inadequate information / Countries that did not respond / Countries not required to respond
(very low MMR)
Botswana / Namibia / Kenya / Angola / Mauritius
Burundi / Rwanda / Lesotho / Madagascar / Seychelles
Comoros / South Africa / Uganda / Mozambique
DR Congo / Swaziland
Eritrea / Tanzania
Ethiopia / Zambia
Malawi / Zimbabwe
Seventeen of the 20 countries (85%) responded by May 15th, 2010, 10 without prompting. Three countries provided inadequate information but were still included in the analysis, since they were part of the first report in 2008. (Mauritius & Seychelles are not included in analysis).
The countries range in population sizes (2006) from 818,000 (Comoros) to 81 million (Ethiopia), with estimated maternal mortality ratio from 123 (South Africa) to 1,100 (Burundi and DRC).
Countries under special circumstances
1. Mauritius and Seychelles.
The two countries have very good health systems for management of safe motherhood and monitoring of maternal deaths. They also have very low MMR, Seychelles has MMR of 1-2/100,000 live births (2008) and Mauritius has MMR of 15/ 100,000 live births (2008) so they are not included in the analysis.
NB: There are no UNFPA COs in the 2 countries.
2. South Africa:
The only country in ESA with a comprehensive confidential enquiry into maternal deaths (CEMD) review system was included in the analysis. It is reported that there is need for improvement in implementation of the recommendations.
A number of countries have visited South Africa to share their experiences, Zimbabwe in 2007 and Botswana, Lesotho, Swaziland, and Ghana in 2009. Many have indicated interest to visit SA to learn from them. This is becoming quite a challenge for the chair of the CEMD to coordinate and manage, since he has other commitments.
3. Ethiopia
In Ethiopia, a detailed maternal mortality review has not yet been set up. Maternal death reviews mainly focusing on quality of clinical care are practiced at some teaching hospitals, but not by other public health facilities. There is therefore no national system for MDR in place, but it was included in the analysis.
A proposal developed in March 2010 (3), on an initiative for the establishment of Maternal Death Review Practice in Ethiopia was therefore shared with the ESA SRO. This is part of joint programme of work by Government, UN partners of H4 and donors to achieve an outcome of improved access and utilization of quality maternal and newborn health services through supporting implementation of evidence based interventions along a continuum of care to accelerate progress toward achieving
MDG5.
The objective of the proposals is to establish a maternal death review practice in Ethiopia in 100 facilities, nationally using the Confidential Enquiry into Maternal Deaths (CEMD) method and surrounding communities using verbal autopsy method. The summary of findings from all levels will be aggregated and sent to the Federal Ministry of Health for sharing.
4. Madagascar.
Madagascar did not respond, but the assessment of progress of MDR in 2010 was based on the report of the Emergency Obstetric and Newborn Care needs assessment that was conducted in 2009/2010. The report indicated that MDR was not being done in any facility in Madagascar (4).
The assessment was conducted in 294 health facilities that included all hospitals and basic health centers with more than 20 deliveries per month. Data collection included direct observation, review of health facility registers and provider interview. The information was later updated to indicate that MDR is ongoing in some hospitals.
5. Kenya:
In 2007, a system for MDR was established in Kenya, with MDR committees at national level and one province, guidelines developed with 100 people trained, but in 2010 it was reported that the MDR had been scaled down while waiting to update , finalize and disseminate the guidelines for maternal and Perinatal Death Notification and Review. This is likely to lead to loss of momentum.
3.2 National policy and guidelines of MDR in ESA Sub Region.
In 2007, seven countries (35%) and in 2010 thirteen (65%) in ESA reported that their Ministries of Health had developed national MDR policies. Countries with new MDR policies include Comoros, Lesotho, Malawi, Namibia, Rwanda, & Uganda.
In 2007, seven countries (35%) and in 2010, eleven countries (55%) have included MDR in MNCH package. Additional countries in 2010 that had MDR in MCNH package were DRC, Lesotho, Malawi, Namibia, Rwanda and Uganda. Maternal death was a notifiable condition in ten countries (50%) in 2007 and thirteen countries (65%) in 2010, while the process to make it notifiable is ongoing in Botswana, Comoros and Namibia.
3.3. Implementation of MDR
3.3.1 National Committees.
In 2007 National committees had been set up to plan, coordinate and implement MDR activities in only three countries (15%), (Botswana, Kenya and South Africa) and in ten countries (50%) in 2010 in ESA. Additional countries with committees by 2010 are Eritrea, Lesotho, Malawi, Namibia, Rwanda, Swaziland, Uganda and Zimbabwe. In 2007 it was reported that national committees in all three countries (100%) meet regularly while in 2010, they meet regularly in seven countries (70%).
In 2007 eight countries reported that provincial or district MDR committees had been set up in selected provinces or districts (such as Angola, Kenya, Malawi, Mozambique, Tanzania), but no national MDR committees were yet in place. By 2010, however Rwanda has developed MDR committees in all districts while in Uganda, Zambia, and Zimbabwe MDR committees have been established in a few districts and provinces.
3.3.2 National Guidelines. In 2007, nine countries (45%) had developed national MDR guidelines, of which seven countries (77%) had begun to implement the guidelines. In 2010, ten countries (50%) have guidelines and all of them had begun to implement the guidelines.
3.3.3: Capacity building/Training.
While having the necessary national capacity is important, skills transfer from national to local level is essential for scaling up.